Weekly Journal

PD, levodopa, hallucinations and sleep

Difficulty writing was the first symptom of his illness. Then his wife noted his walking was slower, and his face more fixed and rigid. Since diagnosis in 2001, he has taken a very light dose of medications: three doses of 25/100 daily and Mirapex. The doctor comments he has had a long honeymoon period; fortunate man. He sits without expression in the office chair, yet he asks questions. He wonders about the frequent hallucinations his is having. The doctor tells him that hallucinations are very common in PD patients. He relates a story of an older man who sees a young naked woman get into bed between him and his dozing wife. The physician asks the patient whether he reached out to see whether the woman was a hallucination, and he replied he didn’t dare move, for fear he would wake his sleeping spouse. That dream the patient comments, is one he would like to have. Instead, the dog hallucination visits him nightly.

When the honeymoon period runs out, patients begin to experience lapses in the effectiveness of medication. These periods, commonly known as “off” periods become more pronounced as illness progresses. The doctor notes the dopamine- rich cells in the brain lose their ability to store excess dopamine, their buffering capacity wanes and patients begin to vary in their levels of function according to the level of medication that reaches the brain. Here, the physician begins speaking about the importance of avoiding proteins, especially milk proteins in the morning meal. Milk proteins compete strongly with the morning levodopa (Sinemt) for passage into the brain; their presence in the diet inhibits the ability of levodopa to get through the blood- brain barrier. This is the reason for having a non-dairy creamer like Cremora instead of milk in coffee and cereal. Dopamine agonists, like Mirapex do not have this problem.

The physician dips into a discussion of sleep and PD, noting the disease ruins normal sleep architecture, causing sleep to fragment. Patients may doze during the day. Excessive daytime napping impedes sleeping ability during night hours, and works to further weaken normal sleep cycles. The body requires a certain amount of rapid eye movement sleep, when not acquired at night, the person with PD becomes susceptible to hallucinations, which are essentially waking dreams. In a study the physician conducted, he found 26% of patients with PD hallucinated; all 26% had fragmented sleep. Novel tranquilizers, such as Seroquel and Clozaril, when given in small doses in the evening counteract fragmented sleep patterns and encourage slumber. The physician prefers patients have a solid length of time given to sleep, as it is more likely they will acquire the needed amount of dreamtime. With a fixed sleep schedule, patients are less likely to hallucinate.

The practitioner- researcher informs the patient and family about a clinical research study he’s involved in, asking whether the patient would be willing to provide a sample of blood. The aim is to find out whether an agent or biomarker exists in the blood that changes with progression of illness. By identifying such an entity, it would be possible to gauge whether medications can truly inhibit the progression of disease.

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